Healthcare Provider Details

I. General information

NPI: 1003308487
Provider Name (Legal Business Name): KIMBERLY NISHIYAMA DTR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2018
Last Update Date: 06/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20325 N 51ST AVE
GLENDALE AZ
85308-5674
US

IV. Provider business mailing address

20325 N 51ST AVE STE 166
GLENDALE AZ
85308-4624
US

V. Phone/Fax

Practice location:
  • Phone: 602-341-5248
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code136A00000X
TaxonomyRegistered Dietetic Technician
License Number86092429
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: